Breaking stigma: The

question of mental
health reform
March 18, 2014 12:13pm
Tags: mentalhealth, nationalcenterformentalhealth
By LILA RAMOS SHAHANI

Of the 1.4 million Filipinos with disabilities identified in the 2010 National
Census, 14 percent or over 200,000 people had mental disability. But,
once shunned by their own families and communities, largely because of
ignorance and prejudice, who will take care of them? What legal and financial
resources does the state have to care for one of the most vulnerable sectors
in our society?

We see them in our streets, unwashed, strangely aimless and focused at the
same time. We pity them in their ragged clothes, their eyes hollow and cheeks
gaunt, struggling from the weight of everything they own slung upon their
backs. Often, we fear them because we don't understand them, and because
they can sometimes be unpredictable.
Psychotic vagrants, throughout our urban and rural centers, are as gravely
misunderstood as they are widespread. Among many derogatory names, they
have been called the taong grasa. Today, the stigma of mental illness in our
culture remains pervasive. We often hear mental health insults like Brenda
and Abnoy to describe politicians that apparently annoy the general public.

Such attitudes reveal a public view of mental health that is, to say the least,
alarmingly simplistic. While mental health covers mental disability itself which
is the third most common disability in the entire country it encompasses a
far wider range of issues like alcoholism, drug abuse, depression, and even
phobias.

The distinction between mental illness, on the one hand, and mental disability,
on the other, is that the latter is a chronic condition that significantly limits a
patients social functions altogether; in comparison, mental illness can still be
treated on an outpatient basis and can often lead to considerable
improvement.

In this country, acute mental disabilities like psychosis dominate the medical
discourse on mental health. Two of our largest mental health facilities the
Sanctuary Center for psychotic female vagrants and the National Center for
Mental Health (NCMH), both in Mandaluyong City are devoted to the
treatment and rehabilitation of people with varying degrees of mental disorder,
but most of whom have psychosis or schizophrenia (which suggests they are
potentially a threat to themselves and others, and are often out of touch with
reality).

In fact, the mere mention of Mandaluyong often leads to jokes about ones
own mental state. This sense of levity and ridicule paints a stark contrast to
the painful realities experienced by persons with (mental) disability (PWDs),
for whom such conditions, more often than not, are a result of bio-chemical
imbalances rather than moral choices.

Sanctuary
Inside the halls of Sanctuary, head social worker Margarita Ortega walks
about like a proud mother she knows exactly where each mess hall is, and
calls each nurse by her personal nickname. Every now and then a patient
grabs her hand for a mano a traditional request for blessing.

Ortega, along with 34 others, runs this four-hectare facility of the Department
of Social Welfare and Development (DSWD). They currently have 132 women
in their care, all with various mental and learning disabilities. The long-term
goal is to successfully integrate these women back into society by providing
them with therapy sessions and livelihood training.

When not in training, the women are free to roam the compound. There is a
gazebo in the front lawn where they lounge during sunny afternoons. Also a
vegetable patch near the kitchen where they cultivate eggplants and ginger. At
night, they huddle inside the shelter, where several hallways have now been
converted into sleeping quarters. Each has an altar with a statue of Jesus or
Mary standing guard even when Ortega and her team are no longer with
them.

The calm is broken each time a woman goes amok. During such potentially
violent moments, the womens medical and psycho-social needs are
particularly urgent, and Ortegas team gets into business.
Never mind that the shelter continuously strains beyond its 100-bed capacity
each passing day. We can never reject referrals, Ortega says. Even in the
shadow of night, they take in abandoned women who have been brought to
them by different local government units (LGUs) in Metro Manila and
neighboring provinces.

National Center for Mental Health

Many of the referrals, of course, come from just blocks away--from the NCMH
itself.

The 4,200-bed NCMH already comprises the bulk of the Department of

Healths (DOH) 5,465-bed capacity for mental disorders. The remaining 1,265
are distributed all over the country. Six regions Ilocos, Calabarzon, Northern
Mindanao, Davao, CARAGA, and ARMM representing over 31 million
people, do not have inpatient psychiatric facilities. Of all the countrys
provinces, Cavite is the only one with a psychiatric facility.

Most cases of mental disability, therefore, are referred to the NCMH, which
has the unique mandate of caring for and conducting research on Filipinos
with mental disability.

The public rarely sees beyond the NCMHs gates. Only workers and relatives
of the hospitals wards are allowed past the security guards. All others must
secure a permit from the hospital administration to enter. Dr. Bernardino
Vicente, NCMHs indefatigable director, oversees the granting of permits
and a great deal more.

The 47-hectare NCMH serves an average of 56,000 outpatients a year. Thats

on top of the 3,000 or so inpatients the NCMH shelters in its 35 pavilions at
any given day. And yet the DOH can only allot a mere P150 per bed to the
NCMH P60 of which goes to food, P12 for medication, and the remaining
P78 divided for utilities such as water, electricity, and fuel.

Perennial underfunding, of course, is the scourge of many of our public

hospitals. Often, both Sanctuary and NCMH have had to resort to soliciting
donations from the private sector even for the most basic supplies, like
bathing soap.

It is no secret that the NCMH had been peddled for privatization as early as
1968. The ballooning number of patients, as well as the rising costs of
operation, has put a strain on the countrys health spending. As Dr. Vicente
asks, almost rhetorically: Kikita ka ba sa mental? (Will you earn profit from
running a mental hospital?)
To centralize or to de-centralize?

But, ultimately, the problems seem to be more structural than financial. For
one thing, the country lacks a comprehensive mental health law to address
many of the countrys mental health needs.

This has been exacerbated by the fact that the Local Government Code of
1991 had devolved the provision of health care to LGUs. While this was
meant to be a move against imperial Manila and to reflect the growing
worldwide trend of decentralizing health care services eventually advocated
by the World Health Organization itself it also implied that the task of
implementing many of the DOHs programs fell on LGU officials, many of
whom lacked training and expertise, particularly in the area of mental health.

In 2001, then-DOH Secretary Manuel Dayrit drafted a national mental health

policy, broadly outlining the goals of mental health care in the country. The
National Objectives for Health: 2005-2010, following the WHO, specified
strategies for reform from an institutionally-based mental health system to
one that was more consumer-focused.

But it was only in 2007 that Congressman Prospero Nograles would file
House Bill 6679, which sought to transfer the administration of mental health
services from NCMH to a Philippine Council for Mental Health. Though the
Council could hypothetically be attached to the DOH, it would also be
composed of representatives from the academe and the private sector, not all
of whom were necessarily answerable to DOH.

The bill, in calling for a more community-based approach to mental health

care, suggested that budgetary and legal power should be slowly taken away
from DOH and NCMH altogether. Perhaps because of its lack of inclusivity
vis--vis critical stakeholders in the mental health field, the bill was eventually
scuttled due to lack of support.

Vicente himself doubts just how ready barangay health centers currently are
to care for people with mental disabilities. Many doctors in our communities
do not know how to treat the mentally ill, he explains. Meron dyan,
pangatlong suicide na, hindi pa nire-refer sa psychiatrist (In some cases, they
still dont refer a patient to a psychiatrist even if its already their third suicide
attempt).

Vicente adds that, in many provincial hospitals and rural health clinics, there
are no available positions for psychiatrists whatsoever.

Today, there are fewer than 500 certified psychiatrists in the country, 91 of
them already employed by the NCMH. This means that there is less than one
psychiatrist for every 150,000 Filipinos.

The solution, Lopez thinks, is not an either-or, mutually exclusive response to

the question of centralization versus de-centralization. She advocates striking
a balance between a centralized mental health facility with expertise in dealing
with advanced cases, on the one hand, and community health centers, which
can help decongest centralized hospitals and provide patients with community
support, on the other. She further recommends the creation of different types
of inpatient and outpatient mental health facilities that will cater to patients
with varying degrees of mental illness.

Natural disasters

These problems, as you can well imagine, are further exacerbated by natural
disasters. Lopez, who has recently been elected to the United Nations
Subcommittee on the Prevention of Torture and Other Cruel, Inhuman or
Degrading Treatment or Punishment, is also the lead convenor of the Citizens
Network for Psychosocial Response to Disasters (CNETPSR)a broad
coalition of more than 20 organizations seeking to institutionalize psychosocial
services in times of disasters and calamities.

Complex emergencies are often part of our everyday lives, Lopez says,
highlighting the fact that people in affected areas need psychosocial services
just as much as they need food or medicine. The CNETPSR was among the
many collective NGOs who flew to Tacloban in the aftermath of supertyphoon
Yolanda to provide counseling and debriefing not only to victims but to health
and social workers themselves.

NGOs like the Philippine Mental Health Association (PMHA) can also help fill
these gaps. In 2012, the PMHA pioneered a tele-psychiatry program, where
general practitioners in the provinces were able to consult, via video
conferencing, with psychiatrists in Manila to prescribe psychiatric medication
for their patients.

The absence of a law

Despite such laudable initiatives, Lopez stresses that it is still critical that a
comprehensive mental health law be crafted in this country, particularly since
the Philippines is a signatory to the Convention of the Rights of Persons with
Disabilities (CRPD). At the moment, the country is also governed by laws with
different goals, like the Penal Code, Magna Carta for PWDs, Family Code,
and the Dangerous Drugs Act.

Similarly, mental health patients can be found in any number of government

facilities covering very distinct mandates. For instance, the Sanctuary is run
by DSWD, while the NCMH is run by the DOH. This has resulted in a mental
health care system that can be disjointed and often inaccessible to those with
little knowledge of psychiatry.

On the upside, the current national mental health program is already being
revamped. Dr. Jasmine Peralta, who oversees the DOHs program on the
treatment and prevention of dangerous drugs, admits that mental health has
not always been given budgetary priority.

That, and the lack of law, are limiting factors kung bakit di tayo makalipad
(That and the lack of a comprehensive law are limiting factors that may
explain why the mental health program still remains unable to take off),
Peralta adds.

Consultations and assessment are under way, however. Among the more
critical options being studied is the establishment of rehabilitation centers at
the regional level, to solve the problem of small municipalities that refuse to
consider mental health important enough to invest in.

Medical requirements

Vicente believes that the impasse on the mental health law is ultimately a
reflection of medical education in the country. Even within the medical
community, he notes, many look down upon psychiatry as a field of practice.

In the current curriculum, students of medicine are required to take no more

than one hour of psychiatry and psychopharmacology. The grueling physician
licensure exams ask a total of only six questions all of them multiple choice
about psychiatry. Despite this, most such questions tend to deal with
psychosis alone, since that happens to be the mental disability most often
requiring institutional incarceration. Unfortunately, this suggests that many
Filipino psychiatrists are not always adequately trained to deal with
depression, substance abuse or phobias.

Psychiatry has to be given some credence, Vicente says with a sigh. Despite
these overwhelming odds, Vicente, Lopez and Peralta remain undeterred.
They know what the problems are, and they quietly point to specific solutions.
And they look forward to the day when their work will finally be recognized,
supported and institutionalized by no less than an actual law on mental
health in this country. KBK/HS, GMA News
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